Education And Debate

Management for Doctors: Decision analysis for medical managers

BMJ 1995; 310 doi: (Published 25 March 1995) Cite this as: BMJ 1995;310:791
  1. J G Thornton, honorary consultanta,
  2. R J Lilford, chairmanb
  1. a Department of Obstetrics and Gynaecology, University of Leeds, Leeds LS2 9LN
  2. b Institute of Epidemiology and Health Services Research, University of Leeds, Leeds LS2 9LN
  1. Correspondence to: Dr Thornton.

    Case study

    The obstetricians at “Enterprise Hospital Trust” in the northern city of Yeeds are trying to persuade the health authority to buy serum screening for Down's syndrome for all pregnant women in the district.1 The director of purchasing was about to approve this when she received a letter from Lady Pressure, chair of the community health council. Lady Pressure's grandchild had just died of congenital toxoplasmosis, and she wondered why this screening was not offered in Yeeds. She enclosed literature from the Toxoplasmosis Trust calling for a screening programme, and reminded the manager that screening had been offered in France for years. Why was Yeeds so backward? Finally, the manager herself was aware that the recent identification of the cystic fibrosis gene made screening for that disease technically simple.

    The right decision in this case is not obvious. It is tempting to choose the cheapest programme, but perhaps a slightly more expensive one will produce greater health gain. This itself is difficult to measure, and different programmes do not simply save different numbers of lives. How can we compare prevention of the birth of a baby with Down's syndrome with the birth of a baby with cystic fibrosis? Each programme will also have other “costs”: they will cause some miscarriages and make quite a few parents anxious.

    Typically, managers resolve such conflicts by reference to previous practice and to what others do and by subjectively evaluating the claims of the various pressure groups. The problem with such political methods is that “he who shouts loudest” is likely to win, without necessarily being the most deserving. Sometimes decision makers will want to stand back and attempt a more thoughtful analysis.

    Decision analysis

    Decision analysis is a way of doing this by analysing the benefits and harms systematically, so that the trade offs are …

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